HEALTH AND HEALTH POLICY
RESEARCH REPORT
Racial/Ethnic Differences in
Uninsurance Rates under the ACA
Are Differences in Uninsurance Rates Projected to Narrow?
Lisa Clemans-Cope
Matthew Buettgens
Hannah Recht
December 2014
ABOUT THE URBAN INSTITUTE
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ABOUT THE FUNDER
The Low-Income Working Families project builds on more than a decade of research under the Assessing the New
Federalism project, which followed struggling families as many left welfare.
The Low-Income Working Families (LIWF) project tracks the well-being of low-income families over time and
analyzes the risks these families face. Our researchers identify the factors that contribute to poor outcomes for
these families and policy options that would reduce barriers and promote meaningful work for adults and positive
outcomes for children.
This project is made possible through generous funding from the Annie E. Casey Foundation. Any opinions and
conclusions expressed herein are those of the authors and do not necessarily represent the views of the Annie E.
Casey Foundation or the Urban Institute and its sponsors or trustees.
Copyright © December 2014. Urban Institute. Permission is granted for reproduction of this file, with attribution to
the Urban Institute. Cover image from Jeff Roberson, Associated Press.
Contents
Acknowledgments
v
Executive Summary
vi
Introduction
1
Methods
3
The Microsimulation Model
3
Measures of Projected Coverage Changes by Racial/Ethnic Group
5
Projected Uninsured Rate Reductions by Racial or Ethnic Group
8
Latinos, Blacks, and American Indian/Alaska Natives are Overrepresented among the Uninsured at
Baseline without the ACA
8
Uninsurance Rates Projected to Fall for all Racial/Ethnic Groups under the ACA with Current
Medicaid Expansion Decisions
9
Are Differences in Uninsurance Rates Projected to Narrow under the ACA with Current Medicaid
Expansion Decisions?
13
Under the ACA with Full Medicaid Expansion, Uninsurance Rates Are Projected to Fall Further for
All Racial/Ethnic Groups, Particularly for Blacks
14
Are Differences in Uninsurance Rates Projected to Narrow under the ACA with Full Medicaid
Expansion?
14
Small Groups of States Account for Most Projected Coverage Gains by Racial or Ethnic
Group
16
Whites (Tables B.3 and B.4)
16
Latinos (Tables B.5 and B.6)
16
Blacks (Tables B.7 and B.8)
17
Asian/Pacific Islanders (Tables B.9 and B.10)
17
American Indian/Alaska Natives (Tables B.11 and B.12)
18
Projected Uninsured Rate Reductions by Racial and Ethnic Subgroups
For Latino-Origin Groups, Uninsurance Rates Are Projected to Decrease
19
19
For Asian/Pacific Islander–Origin Groups, Uninsurance Rates Are Projected to Decrease, but Wide
Differences Remain
22
For American Indian/Alaska Native Tribes, Uninsurance Rates Are Projected to Decrease, but Wide
Differences Remain because of State Expansion Decisions
24
Conclusions
26
Appendix A. Racial and Ethnic Classifications
29
Appendix B. Additional Tables
31
Notes
44
References
47
About the Authors
48
Acknowledgments
This report is part of the Urban Institute’s Low-Income Working Families project, a multiyear effort that
focuses on the private- and public-sector contexts for families’ success or failure. Both contexts offer
opportunities for better helping families meet their needs. The Low-Income Working Families project is
currently supported by the Annie E. Casey Foundation. Any opinions and conclusions expressed herein
are those of the authors and do not necessarily represent the views of the Annie E. Casey Foundation or
the Urban Institute and its sponsors or trustees.
The nonpartisan Urban Institute publishes studies, reports, and books on timely topics worthy of
public consideration. The views expressed are those of the authors and should not be attributed to the
Urban Institute, its trustees, or its funders.
The authors would like to thank the Low Income Working Families project and the Annie E. Casey
Foundation for their generous support of this project; the working-group participants who graciously
shared their time and insights; and Mary Howard, John Keating, and Rachel Langford for their careful
review.
This report has benefited from the helpful comments of Margaret Simms, Genevieve Kenney, and
Stephen Zuckerman. The authors thank Dean Resnick and Victoria Lynch of the Urban Institute’s
Health Policy Center for their assistance in developing data used in the Health Insurance Policy
Simulation Model–American Community Survey.
EXECUTIVE SUMMARY
V
Executive Summary
This report is the first state-level examination of how the Affordable Care Act (ACA) is projected to
change uninsurance rates for five major racial/ethnic groups: whites, Latinos, blacks, Asian/Pacific
Islanders, and American Indian/Alaska Natives. The Urban Institute’s Health Insurance Policy
Simulation Model–American Community Survey microsimulation projects large percentage reductions
in uninsurance rates for all racial and ethnic groups under the ACA with Medicaid expansion decisions
as of December 2014. We project even larger reductions under the ACA with Medicaid expansion in all
states (“full Medicaid expansion”). In a more detailed subgroup examination by origin (i.e., identity
relating to family ancestry or birthplace), we also find large reductions for all Latino-origin groups, all
Asian/Pacific Islander–origin groups, and all American Indian/Alaska Natives tribes.
According to our projections, the ACA with current Medicaid expansion decisions can substantially
narrow differences in uninsurance rates between whites and all racial/ethnic minorities, except blacks,
who disproportionately live in nonexpansion states. Dramatic reductions are projected for the
American Indian/Alaska Natives uninsurance rate: a decrease from 25.7 percent to 13.0 percent, or a
49.5 percent reduction that translates to 600,000 gaining coverage. Latinos have a projected decrease
in the uninsurance rate from 31.2 percent to 19.0 percent: a 39.2 percent reduction that translates to
6.6 million gaining coverage. Both groups’ projections lead to a narrowing of the difference in their
uninsurance rates compared with whites.
Under the ACA with full Medicaid expansion, uninsurance rates are projected to fall further for all
racial and ethnic groups. Compared with projections using the ACA with current Medicaid expansion
decisions, dramatic uninsurance rate reductions are projected for blacks were all states to expand
Medicaid: from 11.3 percent with current expansion decisions to 7.2 percent with full expansion. This is
because over half of all blacks are living in states not expanding Medicaid in 2014; 1.4 million uninsured
blacks are in the eligibility gap. These 1.4 million constitute 23.1 percent of the black adult uninsured
adult population nationwide. Because of tribe members’ locations, four American Indian/Alaska Natives
tribes (Eskimo, Cherokee, Sioux, and Lumbee) are also projected to experience dramatic gains under the
ACA with full Medicaid expansion compared with current expansion decisions.
Even with current Medicaid expansion decisions, the ACA is projected to shrink many of the longstanding racial/ethnic differences in health insurance coverage. Medicaid expansion in all states shows
the potential for further reductions in uninsurance rates and, in contrast with projections of current
Medicaid expansion decisions, would reduce racial differences in coverage between whites and blacks.
VI
EXECUTIVE SUMMARY
State outreach and enrollment efforts will be crucial in (1) raising enrollment rates in Medicaid and
CHIP among eligible individuals and (2) increasing Marketplace enrollment among those who are
eligible for, but are not using, the subsidies available in the insurance Marketplaces.
EXECUTIVE SUMMARY
VII
Introduction
The Affordable Care Act’s (ACA’s) coverage provisions are reducing uninsurance rates: initial estimates
1
suggest reductions may be particularly marked among blacks and Latinos. Several ACA provisions have
contributed to this coverage expansion. The law’s Medicaid expansion provision set a nationwide
eligibility standard: adults with family income up to 138 percent of the federal poverty level (FPL). This
Medicaid expansion was made a state option by the US Supreme Court’s 2012 decision. As of December
2014, 27 states and the District of Columbia had expanded Medicaid or planned to expand by January
2015 (“expansion states”).
2
In addition to the Medicaid expansion, the ACA includes other provisions designed to increase rates
of health insurance coverage: (1) state-based health insurance Marketplaces offering coverage starting
in 2014; (2) health insurance market reforms that have been phasing in since the law passed in 2010; (3)
premium subsidies for many with income below 400 percent of FPL, available through both the federal
3
and state health insurance Marketplaces; and (4) a requirement that all individuals obtain health
insurance coverage.
Many nonelderly adults (ages 19 to 64) with income below 138 percent of FPL who live in states
that have not chosen to expand Medicaid by January 2015 (“nonexpansion states”) fall into the
“coverage gap”: they are not eligible for Medicaid under their states’ eligibility rules but are also
4
ineligible for Marketplace premium subsidies. Because racial and ethnic compositions vary across
states, these state policy decisions can have a major effect on the racial/ethnic composition of poor
individuals in the Medicaid coverage gap (Kenney et al. 2012).
In addition, the ACA excludes particular immigrant groups from new coverage options.
Undocumented immigrants are prohibited from enrolling in Medicaid or purchasing coverage through
the Marketplaces. Undocumented immigrants are projected to compose approximately one-quarter of
the uninsured population after the ACA’s major provisions are implemented, including states’ Medicaid
5
expansions (as those expansion decisions stand in December 2014). Further, the ACA options available
to lawfully residing immigrants vary depending on the number of years they have lived in the United
States.
This study builds on a previous national analysis (Clemans-Cope et al. 2012) and is the first statelevel analysis to project coverage gains for detailed racial/ethnic groups and subgroups by origin (i.e.,
identity relating to family ancestry or birthplace) under the ACA. Three coverage projection scenarios
are compared. Each scenario projects outcomes as of 2016, at which time the current provisions of the
RACIAL/ETHNIC DIFFERENCES IN UNINSURANCE RATES UNDER THE ACA
1
ACA are assumed to be fully implemented. The first scenario projects uninsurance rates in 2016 if the
ACA had not been passed. The second scenario projects uninsurance rates in 2016 under the states’
Medicaid expansion decisions as of December 2014. The third scenario projects uninsurance rates in
2016 if all states were to implement the ACA’s Medicaid expansion.
These findings shed light on whether specific state Medicaid expansions and outreach and
enrollment efforts could affect coverage gains among different racial and ethnic groups.
2
RACIAL/ETHNIC DIFFERENCES IN UNINSURANCE RATES UNDER THE ACA
Methods
We use microsimulation to examine projected coverage changes for different racial and ethnic groups
in 2016. We compare projected coverage in 2016 across three scenarios: (1) had the ACA not been
passed, (2) the ACA with current Medicaid expansion decisions, and (3) the ACA with Medicaid
expansion in all states (“full Medicaid expansion”). Comparing the second and third scenarios with
projected baseline coverage in 2016 had the ACA not been passed allows us to estimate racial/ethnic
coverage effects of the alternative ACA scenarios.
6
The Microsimulation Model
The projections are based on the Urban Institute’s Health Insurance Policy Simulation Model–American
Community Survey (HIPSM-ACS) (Buettgens et al. 2013). This model uses ACS data from 2009, 2010,
and 2011 to obtain representative samples of nonelderly populations (ages 0 to 64) both by state and
by pre-ACA insurance coverage. All estimates and projections presented in this report refer to the
nonelderly population. The Health Insurance Policy Simulation Model simulates individual and family
health insurance enrollment under the ACA by using eligibility for programs and subsidies, health
insurance coverage and options in the family, health status, sociodemographic characteristics, any
7
applicable penalties for remaining uninsured, and other factors. Estimates based on previous versions
8
of HIPSM differ slightly because of revisions and updated regulations. Eligibility for subsidized
marketplace coverage is determined by considering (1) state decisions to expand Medicaid under the
ACA and (2) access to employer-sponsored insurance coverage.
We model eligibility status for Medicaid and the Children’s Health Insurance Program and
subsidized coverage in the Marketplaces, and then use the HIPSM to simulate the decisions of
employers, families, and individuals to offer or enroll in health insurance coverage. We then map those
results to the ACS, using regression modeling to assign probabilities of take-up. To calculate the effects
of reform options, the HIPSM uses a microsimulation based on the relative desirability (utility) of the
9
health insurance options available to each individual and family under reform, considering people’s
10
current choices as reported in the survey data. The resulting health insurance decisions made by
individuals, families, and employers are calibrated to findings in the empirical economics literature
(including, importantly, the price elasticities for employer-sponsored insurance and nongroup
coverage).
RACIAL/ETHNIC DIFFERENCES IN UNINSURANCE RATES UNDER THE ACA
3
Defining Racial/Ethnic Groups
We start by examining coverage changes for five major racial/ethnic groups:
11
1.
White non-Latino (“white”)
2.
Latino
3.
Black non-Latino (“black”)
4.
Non-Latino Asian/Pacific Islander (“Asian/Pacific Islander” or “A/PI”)
5.
American Indian/Alaska Native (“AI/AN”)
We classify people as uninsured without the ACA if they did not report health insurance. Also, we
do not count the Indian Health Service as health insurance coverage because of limitations in its scope
of available services and in the geographic reach of its facilities (Turner and Boudreaux 2010). In this
approach we follow previous research (Clemans-Cope et al. 2012). Because the data are collected
continuously over a 12-month period, our coverage estimates represent an average day in the calendar
year.
We then examine three racial/ethnic groups in additional detail. We analyze subgroups by origin for
the Latino and Asian/Pacific Islander groups because they have relatively high proportions of foreignborn individuals compared with the three other racial/ethnic groups. We analyze American
Indian/Alaska Natives subgroups by tribe. The racial/ethnic subgroups are as follows:
1.
The 11 largest Latino-origin groups (Mexican, Puerto Rican, Salvadoran, Cuban, Dominican,
Guatemalan, Colombian, Honduran, Ecuadorian, Spaniard, and Peruvian) and three other
categories (other South American, other Central American, and other Latino not specified).
2.
The five largest A/PI-origin groups (Chinese, Indian, Filipino, Vietnamese, and Korean) and all
other Asian/Pacific Islanders (including those reporting multiple subgroups).
3.
The nine largest identifiable AI/AN subgroups by tribe (Navajo, Cherokee, Sioux, Chippewa,
Choctaw, Apache, Lumbee, Pueblo, and Eskimo), with all other American Indian/Alaska Natives
(including those of mixed race and multiple tribes) grouped into an “all other American
Indian/Alaska Natives” category. Because nearly three-quarters of American Indian/Alaska
Natives reported either no tribal affiliation or multiple races in the ACS, and because our
estimates for the individual tribes include only those who reported a sole tribal affiliation and
no other race/ethnicity, we undercount the number in each tribal group gaining coverage, but
not the total number of American Indian/Alaska Natives.
4
RACIAL/ETHNIC DIFFERENCES IN UNINSURANCE RATES UNDER THE ACA
Latino-origin, A/PI-origin, and American Indian/Alaska Native tribes are based on self-reported
answers to detailed questions on racial identity relating to family ancestry or birthplace. See appendix A
for more details on race, ethnicity, tribe, and origin classification.
Assigning Undocumented Immigrant Status
The imputation process assigns undocumented status as follows: Noncitizens are those without US
citizenship, including both lawfully present immigrants—some of whom are legal permanent residents—
and undocumented immigrants. An undocumented immigrant is a foreign national who entered the
United States either with a visa as a temporary resident, then overstaying the visa or engaging in
12
activities forbidden by the visa, or without a visa. We impute documentation status for noncitizens in
each year in two stages, using both individual and family characteristics, based on an imputation
methodology originally developed by Jeffrey Passel for the Current Population Survey Annual Social
and Economic Supplement.
An estimated one-sixth of Latinos are undocumented, accounting for 69.7 percent of all
13
undocumented immigrants. A forthcoming brief details coverage changes for Latinos by
documentation status, which varies by origin group (Clemans-Cope et al., forthcoming).
Measures of Projected Coverage Changes by
Racial/Ethnic Group
Absolute and Relative Changes in Uninsurance Rates by Race/Ethnicity Nationally
For each racial/ethnic group, we assess how uninsurance rates are projected to change at the national
level under each of the three scenarios. We examine absolute difference and percent difference in the
uninsurance rate for each racial/ethnic group, comparing the uninsurance rate without the ACA to
those under the ACA with current Medicaid expansion decisions and those under the ACA with full
Medicaid expansion for each racial/ethnic group.
The simplest method of comparing how the ACA affects different racial and ethnic groups’
coverage is to examine the difference in uninsurance rates between groups. We find racial/ethnic
uninsurance rate differences by subtracting the rate of uninsurance for one racial/ethnic group from
RACIAL/ETHNIC DIFFERENCES IN UNINSURANCE RATES UNDER THE ACA
5
that of another, providing percentage-point differences in uninsurance rates between racial/ethnic
group pairs. Whites, whose uninsurance rates are lowest in the baseline scenario, are the reference
group for these differences (thus, for example, we will assess the black-white difference in uninsurance
rates).
14
Assessing Whether Differences in Uninsurance Rates Could Narrow by
Race/Ethnicity Nationally
Though we assess the absolute and relative differences in uninsurance rates between whites and other
racial/ethnic groups, that assessment may not always be sufficient to determine whether the underlying
15
differences in health coverage between racial/ethnic groups have narrowed. Absolute and relative
differences in uninsurance rates between groups provide different types of information and may lead to
different conclusions. Moreover, as uninsurance rates for all groups decline, the relative difference
16
between the groups will tend to increase (all other factors remaining equal). For example, the absolute
percentage-point difference in uninsurance rates between blacks and whites is smaller under the ACA
with current Medicaid expansion decisions than without the ACA (a difference of 5.0 percentage points
versus a difference of 6.5 percentage points; see table 1 on page 12), suggesting that the differences in
health coverage rates narrowed. But the percentage decrease in the uninsurance rate is larger for
whites than for blacks under the ACA with current Medicaid expansion decisions (51.6 percent versus
42.3 percent), suggesting that differences in health coverage between blacks and whites did not
narrow.
17
To draw conclusions about changes in health coverage differences between racial/ethnic minorities
and whites, we compute an additional metric that has advantageous properties not shared by measures
that rely on absolute risk differences. Several metrics have been developed that avoid the problems of
simpler measures of absolute or relative difference. The metric we use is similar to measures of
association, such as relative risk, and we use it here to quantify the size of the difference in coverage
rates between two groups and assess whether differences have narrowed. We calculate this metric for
each racial/ethnic minority group as the correlation between two binary variables (also known as an
“effect size”): being uninsured and being of a particular racial/ethnic minority group. We compute four
metrics for the four race/ethnicity group pairs (black versus white, Latino versus white, American
Indian/Alaska Native versus white, and Asian/Pacific Islander versus white) using whites as the
reference group in each pair (table B.13). To compute this metric, we used a standard measure of
association for two binary variables: the φ statistic based on the χ-squared test:18
6
RACIAL/ETHNIC DIFFERENCES IN UNINSURANCE RATES UNDER THE ACA
𝜒𝜒 2
𝜑𝜑 = �
𝑁𝑁
where N is the weighted number of people in our dataset. If there were no differences in health
coverage between whites and a given racial/ethnic group, this statistic would be 0. In this report, under
all scenarios this statistic is greater than 0 for all racial/ethnic group pairs, meaning that differences in
health coverage exist in all scenarios. For all racial/ethnic group pairs, we compute the statistic without
the ACA, under the ACA with current state Medicaid expansion decisions, and under the ACA with all
states expanding Medicaid. If the statistic for a given group relative to whites is lower under the ACA
than without the ACA, we can conclude that the underlying difference in health coverage has narrowed.
State Changes in Uninsurance Rates by Race/Ethnicity and by Origin Group
For each racial/ethnic group, we assess how uninsurance rates are projected to change at the state level
under the three projected scenarios. For the third such scenario, ACA with full Medicaid expansion, we
assess how geographically concentrated the projected coverage gains would be for each racial/ethnic
group. (See tables B.1–B.12 for further state-level detail.) We also produced estimates of the uninsured
for each racial/ethnic group for the smallest statistically representative geographic area on the ACS.
20
19
Additional estimates and maps are available in a MetroTrends blog post. For three detailed subgroups
(Latino-origin, Asian/Pacific Islander–origin, and American Indian/Alaska Native tribe) we compare
projected percentage reductions in uninsurance rates.
RACIAL/ETHNIC DIFFERENCES IN UNINSURANCE RATES UNDER THE ACA
7
Projected Uninsured Rate
Reductions by Racial or Ethnic
Group
In this section, we assess how uninsurance rates for each racial/ethnic group are projected to change
nationally under each of the three scenarios. We analyze whether racial/ethnic differences in
uninsurance rates are projected to narrow under each scenario.
Latinos, Blacks, and American Indian/Alaska Natives Are
Overrepresented among the Uninsured at Baseline
without the ACA
Without the ACA, blacks make up make up 13.8 percent of the uninsured but only 12.6 percent of the
nonelderly population (figure 1). Latinos make up 33.8 percent of the uninsured but only 19.4 percent of
the population. American Indian/Alaska Natives make up 2.6 percent of the uninsured but only 1.8
percent of the population. Whites, Asian/Pacific Islanders, and other non-Latinos, in contrast, have
lower uninsurance rates than their representation in the population.
8
RACIAL/ETHNIC DIFFERENCES IN UNINSURANCE RATES UNDER THE ACA
FIGURE 1
Uninsured Nonelderly Population Compared with Total Nonelderly Population without the ACA, by
Racial/Ethnic Group
Latinos are 19 percent of the population but 34 percent of the uninsured; whites are 59 percent of the
population but 43 percent of the uninsured.
Percent of total
70
Total
60
50
Uninsured
40
30
20
10
0
White
Latino
Black
Asian/Pacific Islander
American
Indian/Alaska Native
Source: HIPSM-ACS 2014.
Notes: “Others” (not shown here) compose 1.5 percent of the nonelderly population and 1.1 percent of the uninsured without the
ACA. These data are projections for 2016 as described in the Methods section of this report.
Uninsurance Rates Projected to Fall for all Racial/Ethnic
Groups under the ACA with Current Medicaid Expansion
Decisions
Without the ACA, Latinos are projected in 2016 to have the highest uninsurance rate (31.2 percent),
followed by American Indian/Alaska Natives (25.7 percent), blacks (19.6 percent), and Asian/Pacific
Islanders (17.3 percent; see figure 2). Whites have the lowest uninsurance rate without the ACA at 13.1
percent. The ACA with current Medicaid expansion decisions is projected to lead to large reductions in
uninsurance rates for all racial/ethnic groups examined. The rank order of uninsurance rates across
RACIAL/ETHNIC DIFFERENCES IN UNINSURANCE RATES UNDER THE ACA
9
racial/ethnic groups is projected to be unchanged: Latinos still with the highest (19.0 percent), followed
by American Indian/Alaska Natives (13.0 percent) and blacks (11.3 percent); the lowest uninsurance
rates are still projected to be among Asian/Pacific Islanders (8.9 percent) and whites (6.3 percent).
FIGURE 2
Projected Uninsurance Rates by Racial/Ethnic Group under Three ACA Scenarios
Percent uninsured
35
Latino
30
American Indian/
Alaska Native
25
Black
20
Asian/
Pacific Islander
15
White
10
5
0
Without ACA
ACA with current
Medicaid decisions
ACA with full
Medicaid expansion
Source: HIPSM-ACS 2014. ACA simulated as fully implemented in 2016.
The largest absolute reductions in uninsurance rates under the ACA with current Medicaid
expansion decisions are projected to be among minority groups, especially American Indian/Alaskan
21
Natives (a 12.7 percentage-point drop) and Latinos (a 12.2 percentage-point drop). The absolute
reduction is somewhat less for blacks and Asian/Pacific Islanders (an 8.3 percentage-point drop for
both). In comparison, the uninsurance rate among whites is expected to fall 6.8 percentage points,
smaller than the drops projected for minority groups.
Uninsurance rates vary greatly by race and ethnicity in the “without ACA” scenario. Thus, the
racial/ethnic groups with the largest percentage-point drops in the uninsurance rate do not correspond
10
RACIAL/ETHNIC DIFFERENCES IN UNINSURANCE RATES UNDER THE ACA
to the largest relative reductions in uninsurance levels. For example, though Latinos are projected to
have the largest percentage-point decrease in the uninsured rate, they also had the highest rate of
uninsurance at the baseline. Consequently, the relative reduction in the uninsured rate for Latinos is
projected to be smaller than for all other racial/ethnic groups.
Important projected changes in coverage under the ACA with current Medicaid expansion
decisions compared to the “without ACA” scenario include the following (table 1):

22
The uninsurance rate for whites would decrease 51.6 percent from 13.1 percent without ACA
to 6.3 percent under the ACA with current Medicaid expansion decisions: 11.1 million would
gain coverage. Whites would account for 48.9 percent of all coverage gains nationwide.

For Latinos, the ACA with current Medicaid expansion decisions is projected to reduce the
uninsured rate 39.2 percent compared to the “without ACA” scenario from 31.2 percent to 19.0
percent: an estimated 6.6 million Latinos would gain coverage. Although this group would still
have the highest uninsurance rate of all racial and ethnic groups, its coverage gains would
constitute 28.9 percent of all coverage gains.

The uninsurance rate for blacks would decrease 42.3 percent from 19.6 percent to 11.3
percent: 2.9 million would gain coverage. Blacks would account for 12.8 percent of all coverage
gains.

The uninsurance rate for Asian/Pacific Islanders would decrease 48.2 percent from 17.3
percent to 8.9 percent: 1.3 million would gain coverage. Asian/Pacific Islanders would account
for 5.5 percent of all coverage gains.

Dramatic rate reductions are projected for American Indian/Alaska Natives, for whom the
uninsurance rate is projected to decrease 49.5 percent from 25.7 percent to 13.0 percent:
600,000 would gain coverage. American Indian/Alaska Natives would account for 2.8 percent
of all coverage gains.
RACIAL/ETHNIC DIFFERENCES IN UNINSURANCE RATES UNDER THE ACA
11
TABLE 1
Selected Characteristics and Projected Uninsurance Rates under Three ACA Scenarios, by Race/Ethnicity
Without ACA
Race/ethnicity
Total
nonelderly
(millions)
Living in
nonexpansion
states
(%)
Undocumented
immigrants
(%)
Uninsured
(millions)
Uninsurance
rate
(%)
ACA with Current
Medicaid Expansion
Decisions
Decrease
relative to
without
Uninsurance
ACA
rate
(%)
(%)
ACA with Full Medicaid
Expansion
Decrease
relative to
without
Uninsurance
ACA
rate
(%)
(%)
White
Latino
Black
Asian/PI
AI/AN
164.3
53.6
35.0
15.0
5.0
42.3
38.1
54.9
22.9
44.4
0.7
16.4
1.7
12.1
N/A
21.5
16.7
6.8
2.6
1.3
13.1
31.2
19.6
17.3
25.7
51.6
39.2
42.3
48.2
49.5
6.3
19.0
11.3
8.9
13.0
64.5
46.7
63.2
53.6
61.6
4.6
16.6
7.2
8.0
9.9
All
277.0
41.9
4.5
49.5
17.9
45.9
9.7
57.6
7.6
Source: HIPSM-ACS 2014. ACA simulated as fully implemented in 2016.
Notes: PI = Pacific Islander; AI/AN = American Indian/Alaska Native; N/A = not applicable. Population is all nonelderly. Cells marked “not applicable” had too small of a sample size to
provide meaningful data. “All” includes a residual racial/ethnic category: those who selected “some other race” as their racial category or selected multiple races and are not Latino or
American Indian/Alaska Native. Because of the small samples and heterogeneous nature of this group, this category is not analyzed. See appendix A for additional details on racial/ethnic
categories.
12
RACIAL/ETHNIC DIFFERENCES IN UNINSURANCE RATES UNDER THE ACA
Are Differences in Uninsurance Rates Projected to
Narrow under the ACA with Current Medicaid Expansion
Decisions?
Yes—in most cases the differences in uninsurance rates between racial/ethnic minority groups and
whites are projected to narrow under the ACA with current Medicaid expansion decisions.
First, we examine the projected absolute percentage-point differences in uninsurance. Compared
to without the ACA, the uninsurance rate difference with whites drops for all groups under the ACA
with current Medicaid expansion decisions:

23
The black-white difference in uninsurance rates is projected to fall from 6.5 percentage points
to 5.0 percentage points.

The Latino-white difference is projected to fall from 18.1 percentage points to 12.7 percentage
points.

The Asian/Pacific Islander–white difference is projected to fall from 4.2 percentage points to
2.6 percentage points.

The American Indian/Alaskan Native–white difference is projected to fall from 12.6 percentage
points to 6.7 percentage points.
To assess whether these changes signify a narrowing of the relative difference in uninsurance rates
among the groups, we examine an additional statistic, effect size, to quantify the size of the difference in
coverage rates between two groups (as described in the methods section). For Latinos and American
Indian/Alaska Natives, the difference in uninsurance rates with whites is projected to narrow under the
ACA with current Medicaid expansion decisions compared with uninsurance rates without the ACA
since the statistic is smaller under the latter scenario (table B.13). In addition, the difference between
Asian/Pacific Islanders’ uninsurance rates and whites’ rates, which started out small, is projected to
narrow slightly under the ACA with current Medicaid expansion decisions. For blacks, however, the
difference between their uninsurance rates and whites’ rates is projected to narrow under the ACA
with current Medicaid expansion decisions only in Medicaid expansion states. Across all states, the
difference in uninsurance rates between blacks and whites is projected to stay approximately the same
both under the ACA with current Medicaid expansion decisions and without the ACA.
RACIAL/ETHNIC DIFFERENCES IN UNINSURANCE RATES UNDER THE ACA
13
Under the ACA with Full Medicaid Expansion,
Uninsurance Rates Are Projected to Fall Further for All
Racial/Ethnic Groups, Particularly for Blacks
Uninsurance rates are projected to fall further for all groups under the ACA with full Medicaid
expansion compared with rates under the ACA with current Medicaid expansion decisions. Under both
ACA scenarios, Latinos, American Indian/Alaska Natives, and blacks would have the largest absolute
24
reductions in uninsurance rates. The effects on uninsurance rates under the ACA with full Medicaid
expansion are particularly strong for groups with a high share of potential Medicaid eligibles because
the nonexpansion states tended to have lower Medicaid eligibility rules before the ACA than the
expansion states. Blacks are projected to have the largest decreases in uninsurance rates under full
Medicaid expansion: a drop from 11.3 percent (projected with current expansion decisions) to 7.2
percent (see figure 2 and table 1).
These results are driven in part by how many uninsured in each racial/ethnic group fall into the
“coverage gap” in nonexpansion states. As a share of the adult uninsured population in nonexpansion
states, a disproportionate share of blacks falls into the coverage gap (37.6 percent for blacks compared
with 28.7 percent for whites; data not shown). Accordingly, blacks are projected to have particularly
large gains from additional Medicaid expansions.
Are Differences in Uninsurance Rates Projected to
Narrow under the ACA with Full Medicaid Expansion?
Yes—in most cases differences in uninsurance rates between racial/ethnic minority groups and whites
are projected to narrow under the ACA with full Medicaid expansion relative to differences without the
ACA.
We first examine the projected absolute percentage-point differences in uninsurance. Compared to
the “without ACA” scenario, the uninsurance rate difference with whites drops for all groups under ACA
with full Medicaid expansion:
25
The Latino-white difference is projected to fall from 18.1 percentage points to 12.0 percentage

points.
14
RACIAL/ETHNIC DIFFERENCES IN UNINSURANCE RATES UNDER THE ACA

The black-white difference in uninsurance rates is projected to fall from 6.5 percentage points
to 2.6 percentage points, thus the black-white difference shrinks more under the ACA with full
Medicaid expansion than under the ACA with current Medicaid expansion decisions.

The Asian/Pacific Islander–white difference is projected to fall from 4.2 percentage points to
3.4 percentage points—a smaller decrease than under the ACA with current Medicaid
expansion decisions.

The American Indian/Alaskan Native–white difference is projected to fall from 12.6 percentage
points to 5.2 percentage points.
As above, to assess whether these changes signify a narrowing of the relative difference in
uninsurance rates among the groups, we examine the effect size (table B.13). In contrast to the ACA
with current Medicaid expansion decisions, the national difference in uninsurance rates between blacks
and whites is projected to narrow under the ACA with full Medicaid expansion as compared with the
“without ACA” scenario. This is because the coverage gap in nonexpansion states contains a large
numbers of blacks.
For Latinos and American Indian/Alaska Native groups, the difference in uninsurance rates with
whites is also projected to narrow under the ACA with full Medicaid expansion. Coverage rates for
whites are affected more than coverage rates for Latinos in a given nonexpansion state if that state
were to expand; this is because a small but significant share of poor uninsured Latinos in nonexpansion
states is undocumented and therefore ineligible for Medicaid. For American Indian/Alaska Natives, the
sizable narrowing of the coverage difference with whites is caused by additional enrollment in
nonexpansion states if those states were to expand. For Asian/Pacific Islanders, who started out with a
small coverage difference with whites, the differential is not projected to narrow under the ACA with
full Medicaid expansion.
RACIAL/ETHNIC DIFFERENCES IN UNINSURANCE RATES UNDER THE ACA
15
Small Groups of States Account for
Most Projected Coverage Gains by
Racial or Ethnic Group
A different group of states accounts for disproportionate gains for each racial/ethnic group under the
ACA with full Medicaid expansion. These findings are driven by the underlying distribution of residence
for each group. We first identify the states with the highest potential effect on coverage gains for each
group; we then examine whether these states are Medicaid expansion states or nonexpansion states.
26
Whites (Tables B.3 and B.4)
Under the ACA with full Medicaid expansion, 11 states are found to account for half (6.8

million) of coverage gains for whites. In descending order of size of gain, these states are
California, Florida, Texas, Ohio, Pennsylvania, Michigan, Georgia, North Carolina, Indiana,
Illinois, and New York.
Because 6 of these 11 states (California, Ohio, Michigan, Illinois, New York, and Pennsylvania)

have expanded Medicaid, coverage gains caused by Medicaid expansion are already included in
projections that use current Medicaid expansion decisions.
If the remaining five (Florida, Texas, Georgia, North Carolina, and Indiana) were to expand

Medicaid, the number of whites projected to gain coverage nationwide would increase 25.1
percent (3.3 million) compared with the number of whites projected to gain coverage under the
ACA with current Medicaid expansion decisions.
Latinos (Tables B.5 and B.6)
Under the ACA with full Medicaid expansion, just two states (California, which expanded

Medicaid, and Texas, which has not expanded Medicaid) are projected to account for half (3.4
million) of coverage gains for Latinos.
16
RACIAL/ETHNIC DIFFERENCES IN UNINSURANCE RATES UNDER THE ACA

If Texas expands Medicaid, the number of Latinos projected to gained coverage nationally
would increase 11.3 percent (0.7 million) compared with the number of Latinos projected to
gain coverage under the ACA with current Medicaid expansion decisions.
Blacks (Tables B.7 and B.8)

Under the ACA with full Medicaid expansion, seven states are projected to account for half (2.2
million) of coverage gains for blacks. In descending order of size of gain, these states are Florida,
Georgia, Texas, North Carolina, Louisiana, California, and Illinois.

Because only two of these seven states (California and Illinois) have expanded Medicaid, a small
share of potential coverage gains is projected to occur under the ACA with current Medicaid
expansion decisions.

If the remaining five states (Florida, Georgia, Texas, North Carolina, and Louisiana) were to
expand Medicaid, the number of blacks projected to gain coverage nationwide would increase
30.2 percent (0.9 million) compared with the number of blacks projected to gain coverage
under the ACA with current Medicaid expansion decisions.
Asian/Pacific Islanders (Tables B.9 and B.10)

Under the ACA with full Medicaid expansion, three states (California, Texas, and New York) are
projected to account for half (0.7 million) of coverage gains for Asian/Pacific Islanders.
California would account for 35.9 percent of all national gains.

If Texas were to expand Medicaid, coverage gains for Asian/Pacific Islanders nationwide would
increase by 3.6 percent (46,000) compared with the number of Asian/Pacific Islanders
projected to gain coverage under the ACA with current Medicaid expansion decisions.
RACIAL/ETHNIC DIFFERENCES IN UNINSURANCE RATES UNDER THE ACA
17
American Indian/Alaska Natives (Tables B.11 and B.12)
Under the ACA with full Medicaid expansion, seven states are projected to account for half (0.4

million) of coverage gains for American Indian/Alaska Natives. In descending order of coverage
gain, these are California, Oklahoma, Arizona, New Mexico, Texas, Alaska, and North Carolina.
If the four nonexpansion high-impact states (Oklahoma, Texas, Alaska, and North Carolina)

were to expand Medicaid, coverage gains for American Indian/Alaska Natives nationally are
projected to increase 11.8 percent (75,000) compared with the number of American
Indian/Alaska Natives projected to gain coverage under the ACA with current Medicaid
expansion decisions.
18
RACIAL/ETHNIC DIFFERENCES IN UNINSURANCE RATES UNDER THE ACA
Projected Uninsured Rate
Reductions by Racial and Ethnic
Subgroups
We provide more disaggregated information for three detailed subgroups: Latino-origin, Asian/Pacific
Islander–origin, and American Indian/Alaska Native tribe.
For Latino-Origin Groups, Uninsurance Rates Are
Projected to Decrease
Changes under the ACA with current Medicaid expansion decisions and with full Medicaid expansion
vary widely by Latino-origin group and are driven largely by three factors: rates of uninsurance without
the ACA, state of residence, and the prevalence of undocumented immigrants.
As shown in table 1, compared with other racial/ethnic groups, Latinos have the highest rate of
uninsurance without the ACA: 31.2 percent. Latino uninsurance rates vary by origin without the ACA
and are estimated to range from 15.2 percent for those of Puerto Rican origin to 49.0 percent for those
of Honduran origin (table 2).
Overall, the ACA with current Medicaid expansion decisions is projected to decrease uninsurance
rates 39.2 percent for all Latinos, leaving 19.0 percent uninsured. Wide differences are projected to
remain across Latino-origin groups. The Honduran-origin and Guatemalan-origin populations,
approximately one-third of whom are undocumented, would still have the highest rates of uninsurance:
35.6 percent and 32.0 percent, respectively. Those two populations are also projected to have the
smallest percentage decreases in uninsurance rate of all Latino-origin groups. The Dominican-origin
population, among those with the lowest uninsurance rate without the ACA, would have among the
largest percentage decrease in uninsurance rate across Latino-origin groups: from 22.9 percent to 13.1
percent uninsured, a 42.8 percent drop.
State of residence is also an important factor in projected changes in coverage under the ACA for
Latino-origin groups. Though 27 states and the District of Columbia will expand Medicaid by January
2015, 38.1 percent of Latinos live in states that are not currently planning to expand Medicaid.
RACIAL/ETHNIC DIFFERENCES IN UNINSURANCE RATES UNDER THE ACA
19
Consequently, the uninsurance rate for Latinos would decrease 39.2 percent under the ACA with
current Medicaid expansion decisions; this decrease would be 46.7 percent with full expansion. Thus,
the ACA with current Medicaid expansion decisions would lead to 1.3 million fewer insured Latinos
than with full Medicaid expansion. State decisions’ effect on coverage varies by Latino-origin group
location. For example, four out of five uninsured Cubans live in Florida, which is not expanding Medicaid
as of January 2015 (data not shown). If Florida were to expand Medicaid, an additional 73,000 Cubans
would gain coverage. Nationwide, only 13.3 percent of all Cubans would remain uninsured if all states
expanded Medicaid; 17.8 percent would remain uninsured with current Medicaid expansion decisions.
Under the ACA with full Medicaid expansion, 16.6 percent of Latinos would remain uninsured, a
reduction of 46.7 percent compared with the project uninsurance rate without the ACA. The resulting
uninsurance rates, however, would still vary among Latino-origin groups. The difference between the
ACA with current expansion decisions and with full expansion would be particularly large for those of
Cuban origin, over three-quarters of whom live in states that will not be expanding Medicaid by January
2015. For those of Mexican origin and several other Latino-origin groups, the difference in projected
uninsurance rates between the two ACA scenarios is lessened by the prevalence of undocumented
immigrants among the uninsured. See a forthcoming brief by Clemans-Cope and colleagues for more
details regarding the effect of undocumented immigrants on coverage rates for Latino-origin groups
(Clemans-Cope et al., forthcoming).
20
RACIAL/ETHNIC DIFFERENCES IN UNINSURANCE RATES UNDER THE ACA
TABLE 2
Selected Characteristics and Projected Uninsurance Rates for Latinos by Origin under Three ACA Scenarios
Without ACA
Latinos by
origin
Total
nonelderly
(millions)
Living in
nonexpansion
states
(%)
Undocumented
immigrants
(%)
Uninsured
(millions)
Uninsurance
rate
(%)
ACA with Current
Medicaid Expansion
Decisions
Decrease
relative to
Uninsurance
without
rate
ACA
(%)
(%)
ACA with Full Medicaid
Expansion
Decrease
relative to
Uninsurance
without
rate
ACA
(%)
(%)
Mexican
Puerto Rican
Salvadoran
Cuban
Dominican
Guatemalan
Colombian
Honduran
Ecuadorian
Spaniard
Peruvian
Other S. Am.
Other C. Am.
Other Latino, n.s.
35.2
4.9
2.0
1.8
1.6
1.2
1.0
0.7
0.7
0.6
0.6
0.9
0.8
1.6
38.2
30.2
33.2
77.1
16.8
31.6
48.6
57.3
17.8
32.4
37.6
50.4
48.9
33.8
17.8
N/A
28.1
12.6
9.2
32.8
20.1
34.5
21.5
3.1
24.7
25.3
17.4
3.4
11.8
0.7
0.8
0.5
0.4
0.6
0.3
0.4
0.2
0.1
0.2
0.2
0.2
0.3
33.4
15.2
40.0
28.9
22.9
47.2
28.7
49.0
35.4
15.4
31.6
28.0
30.2
20.7
39.1
50.3
35.6
38.2
42.8
32.3
40.0
27.3
34.6
51.0
35.2
36.0
38.5
50.4
20.3
7.6
25.8
17.8
13.1
32.0
17.3
35.6
23.2
7.6
20.5
17.9
18.5
10.3
46.5
61.0
40.1
54.0
47.9
35.3
48.3
34.7
37.4
60.5
40.1
43.6
48.6
60.8
17.8
5.9
24.0
13.3
11.9
30.5
14.9
32.0
22.2
6.1
18.9
15.8
15.5
8.1
All Latino
53.6
38.1
16.4
16.8
31.2
39.2
19.0
46.7
16.6
Source: HIPSM-ACS 2014. ACA simulated as fully implemented in 2016.
Notes: S. Am. = South American; C. Am. = Central American; n.s. = not specified. See appendix A for additional details on race/ethnicity and origin categories.
RACIAL/ETHNIC DIFFERENCES IN UNINSURANCE RATES UNDER THE ACA
21
For Asian/Pacific Islander–Origin Groups, Uninsurance
Rates Are Projected to Decrease, but Wide Differences
Remain
Though the overall uninsurance rate for Asian/Pacific Islanders without the ACA is projected to be 17.3
percent, lower than that of all other race/ethnic groups except whites, uninsurance rates are projected
to differ widely by Asian/Pacific Islander–origin groups (table 3). Those of Korean origin are projected
to have the highest uninsurance rate without the ACA, 29.9 percent, followed by those of Vietnamese
origin at 21.5 percent. Those of Indian origin and those of Filipino origin are projected to have much
lower uninsurance rates without the ACA: 13.1 percent and 12.4 percent, respectively.
Over three-quarters of Asian/Pacific Islanders live in states that are expanding Medicaid, the
highest rate of any racial/ethnic group. Under the ACA with current Medicaid expansion decisions,
uninsurance rates for Asian/Pacific Islanders are projected to decrease 48.2 percent, falling from 17.3
percent to 8.9 percent. If all states expanded Medicaid, an additional 139,200 Asian/Pacific Islanders
would gain coverage. More than one-quarter of these additional gains would come from those of
Vietnamese origin: 34.5 percent live in states that are not currently expanding Medicaid. Additionally,
this group is projected to experience the largest percentage decrease in uninsurance of any
Asian/Pacific Islander–origin group under the ACA with full expansion: 60.3 percent. Because a large
majority of Chinese-, Asian Indian–, Filipino-, and Korean-origin groups live in states that decided to
expand Medicaid by January 2015, only marginal gains would be made with additional expansions.
22
RACIAL/ETHNIC DIFFERENCES IN UNINSURANCE RATES UNDER THE ACA
TABLE 3
Selected Characteristics and Projected Uninsurance Rates for Asian/Pacific Islanders by Origin under Three ACA Scenarios
Without ACA
Asian/Pacific
Islanders by
origin
Chinese
Asian Indian
Filipino
Vietnamese
Korean
All other A/PI
All A/PI
Total
nonelderly
(millions)
Living in
nonexpansion
states
(%)
Undocumented
immigrants
(%)
Uninsured
(millions)
Uninsurance
rate
(%)
ACA with Current
Medicaid Expansion
Decisions
Decrease
relative to
Uninsurance
without
rate
ACA
(%)
(%)
ACA with Full Medicaid
Expansion
Decrease
relative to
Uninsurance
without
rate
ACA
(%)
(%)
3.4
2.9
2.4
1.6
1.4
3.2
16.5
28.3
16.0
34.5
23.1
23.9
11.4
17.4
10.3
6.5
15.3
10.8
0.6
0.4
0.3
0.4
0.4
0.6
16.5
13.1
12.4
21.5
29.9
17.7
47.5
44.2
49.4
50.0
51.1
47.6
8.7
7.3
6.3
10.7
14.6
9.3
50.8
49.9
52.2
60.3
55.0
54.1
8.1
6.6
5.9
8.5
13.4
8.1
15.0
22.9
12.1
2.6
17.3
48.2
8.9
53.6
8.0
Source: HIPSM-ACS 2014. ACA simulated as fully implemented in 2016.
Notes: A/PI = Asian/Pacific Islander. See appendix A for additional details on racial/ethnic and origin categories.
RACIAL/ETHNIC DIFFERENCES IN UNINSURANCE RATES UNDER THE ACA
23
For American Indian/Alaska Native Tribes, Uninsurance
Rates Are Projected to Decrease, but Wide Differences
Remain because of State Expansion Decisions
Without the ACA, uninsurance rates are projected to vary widely for American Indian/Alaska Natives
by tribe, from 24.4 percent for Chippewa to 34.2 percent for Navajo (table 4). Under the ACA with
current Medicaid expansion decisions, uninsurance rates are projected to fall substantially for all
American Indian/Alaska Native groups. Approximately 633,000 American Indian/Alaska Natives are
projected to gain coverage. Over two-thirds (68.2 percent) of American Indian/Alaska Natives
projected to gain coverage under the ACA with current Medicaid expansion decisions do not report
membership in only a single tribe and thus fall into the “All Other AI/AN” category.
27
Only one-quarter of American Indian/Alaska Natives report only one tribal affiliation and no
additional races. And though potential underreporting of tribal membership and small samples limit
detail on inter-tribal differences, some findings are clear. American Indian/Alaska Natives who report
only one tribal affiliation and no additional races are concentrated in states with tribal jurisdictions;
those reporting no tribe, multiple tribes, or multiple races are much less geographically concentrated.
28
Consequently, differences in coverage gains across tribes are largely based on state Medicaid
expansion decisions.
Thus, though just 13.0 percent of all American Indian/Alaska Natives are projected to be uninsured
under the ACA with current Medicaid expansion decisions, rates vary based on state of residence.
Navajos and Pueblos, with fewer than 10 percent of members living in nonexpansion states, are
projected to have uninsurance rates of 11.8 percent and 11.9 percent, respectively. Lumbees and
Eskimos, with nearly all residents living in nonexpansion states (North Carolina and Alaska,
respectively) are projected to have uninsurance rates of 17.5 percent and 16.3 percent, respectively.
If all states expanded Medicaid, the uninsurance rate among all American Indian/Alaska Natives
would drop to 9.9 percent, a decrease of 61.6 percent compared with projections without the ACA. The
projected uninsurance rates with full expansion would range from 8.7 percent for the Cherokee to 11.7
percent for Pueblos. Eskimos, 9.0 percent of whom would remain uninsured, would see the largest
percentage decrease in uninsurance: 72.7 percent if all states (including Alaska) expanded Medicaid.
24
RACIAL/ETHNIC DIFFERENCES IN UNINSURANCE RATES UNDER THE ACA
TABLE 4
Uninsurance Rates and Decreases for American Indian/Alaska Natives by Tribe
Without ACA
American Indian/
Alaska Natives by
tribe
Total
nonelderly
(thousands)
Navajo
Cherokee
Sioux
Chippewa
Choctaw
Apache
Lumbee
Pueblo
Eskimo
All other AI/AN
All AI/AN
347.2
283.4
141.4
130.6
89.1
76.9
76.4
68.0
66.8
3,688.5
4,968.2
Living in
nonexpansion
states
(%)
9.9
68.9
68.3
24.2
79.5
17.8
96.3
5.4
94.5
44.0
44.4
Uninsured
(thousands)
Uninsurance
rate
(%)
118.7
70.1
44.2
31.9
24.8
23.5
20.3
21.8
22.0
900.7
1,278.0
34.2
24.7
31.3
24.4
27.9
30.5
26.5
32.1
33.0
24.4
25.7
ACA with Current Medicaid
Expansion Decisions
Decrease
relative to
Uninsurance
without
rate
ACA
(%)
(%)
65.6
43.4
41.4
56.7
46.1
57.0
34.1
63.0
50.5
48.0
49.5
11.8
14.0
18.3
10.6
15.0
13.1
17.5
11.9
16.3
12.7
13.0
ACA with Full Medicaid
Expansion
Decrease
relative to
Uninsurance
without
rate
ACA
(%)
(%)
68.3
64.7
67.3
61.2
64.3
65.0
65.9
63.6
72.7
59.7
61.6
10.8
8.7
10.2
9.5
9.9
10.7
9.0
11.7
9.0
9.9
9.9
Source: HIPSM-ACS 2014. ACA simulated as fully implemented in 2016.
Note: AI/AN = American Indian/Alaska Native. Population is all nonelderly. See appendix A for additional details on racial/ethnic categories.
RACIAL/ETHNIC DIFFERENCES IN UNINSURANCE RATES UNDER THE ACA
25
Conclusions
This study is the first state-based examination of how the ACA is projected to change uninsurance rates
for five major racial and ethnic groups: whites, blacks, Latinos, Asian/Pacific Islanders, and American
Indian/ Alaska Natives. The Urban Institute’s HIPSM-ACS microsimulation model projects large
reductions in uninsurance rates for all racial/ethnic groups under the ACA with Medicaid expansion
decisions as of December 2014. We project even larger reductions under the ACA with full Medicaid
expansion. In a more detailed subgroup examination by origin, we also find large reductions for each
Latino-origin group, Asian/Pacific Islander–origin group, and American Indian/Alaska Natives tribe
examined.
According to our projections, the ACA with current Medicaid expansion decisions could
substantially narrow differences in uninsurance rates between whites and all racial/ethnic minorities
except blacks, who disproportionately live nonexpansion states. In particular, dramatic reductions are
projected for American Indian/Alaska Natives, with a projected decrease in the uninsurance rate from
25.7 percent to 13.0 percent—a 49.5 percent reduction that translates to 600,000 gaining coverage.
Latinos would see a projected decrease in the uninsured rate from 31.2 percent to 19.0 percent—a 39.2
percent reduction, translating to 6.6 million gaining coverage. Both groups would see a narrowing of the
differences in uninsurance rates with whites.
Under the ACA with Medicaid expansion in all states, uninsurance rates are projected to fall further
for all racial/ethnic groups. Compared to projections with current Medicaid expansion decisions,
dramatic uninsurance rate reductions are projected for blacks were all states to expand Medicaid: from
11.3 percent with current decisions to 7.2 percent with full expansion. Given that over half of all blacks
are living in states not expanding Medicaid in 2014, 1.4 million uninsured blacks are in the eligibility gap.
These 1.4 million constitute 23.1 percent of the black adult uninsured adult population nationwide.
Overall, 2.7 million whites, 13.8 percent of the white adult uninsured population, falls into this gap.
Because of tribe members’ locations, four American Indian/Alaska Natives tribes (Eskimo, Cherokee,
Sioux, and Lumbee) are also projected to experience dramatic gains under the ACA with full Medicaid
expansion as compared with current expansion decisions.
Even with current Medicaid expansion decisions, the ACA is projected to shrink many of the
persistent racial and ethnic differences in health insurance coverage. The ACA with Medicaid expansion
in all states shows the potential for further reductions in uninsurance rates and, in contrast with
projections of current Medicaid expansion decisions, would substantially narrow racial/ethnic
26
RACIAL/ETHNIC DIFFERENCES IN UNINSURANCE RATES UNDER THE ACA
differences in coverage between whites and blacks. Thus, the promise of reducing long-standing
racial/ethnic differences in access to health care and health status likely depends in part on the
expansion decisions of the remaining 23 states.
Even so, state outreach and enrollment efforts will be important to (1) raise enrollment rates among
eligibles in Medicaid and the Children’s Health Insurance Program and (2) increase the number of
eligible people who purchase subsidized coverage through the new insurance Marketplaces:

Further coverage gains among Latinos will depend heavily on reaching Latinos in California (a
Medicaid expansion state), many of whom are immigrants with limited English proficiency;
those gains will also depend on Medicaid expansion decisions in Texas and Florida.

California will also be pivotal for Asian/Pacific Islanders, many of whom have limited English
proficiency, and for low-income whites, for whom low health insurance literacy may be the
most important obstacle.

Further coverage gains among blacks will depend on effective Medicaid and Marketplace
outreach and enrollment efforts in California and Illinois (also a Medicaid expansion state) and
Medicaid expansion decisions in Florida, Georgia, Texas, North Carolina, and Louisiana.

Further coverage gains for American Indian/Alaska Natives will depend heavily on outreach
and enrollment efforts in Oklahoma and Alaska, which have not expanded Medicaid, as well as
California, Arizona, and New Mexico, which expanded Medicaid in 2014.

Further coverage gains for whites will depend on outreach and enrollment in California, Ohio,
and Pennsylvania (three Medicaid expansion states), and Florida and Texas (two nonexpansion
states). Those gains also depend on Medicaid expansion decisions in Florida, Texas, Georgia,
North Carolina, and Indiana.
The extent to which these high-impact states are maximizing outreach and enrollment efforts
29
across racial/ethnic groups is unknown. But four lessons for racial/ethnic group enrollment identified
during the first open enrollment season may be instructive. First, an effective enrollment process
requires enrollment assistance for those with limited English proficiency. This includes high-quality
translations of print materials, greater availability of one-on-one in-person assistance, and a wellfunctioning website with culturally and linguistically appropriate versions languages besides English
(Brooks 2014). Translation services are particularly important for those with limited English proficiency
(Jahnke, Siddiqui, and Andrulis 2014). Second, the identity verification process posed problems. The
process relied heavily on whether an individual could provide a Social Security number and answer
RACIAL/ETHNIC DIFFERENCES IN UNINSURANCE RATES UNDER THE ACA
27
30
‘identity proofing’ questions drawn from credit history. The process was cited as a barrier for many
immigrant families and those with limited credit history during the first open enrollment season
31
(Kanchinadam and Jee 2014). Third, improving health insurance literacy is likely to improve
enrollment. Health insurance literacy is low among those who are eligible for Medicaid. This impedes
enrollment, and some racial/ethnic groups, such as Latinos, face larger health insurance literacy gaps
than other groups (Long and Goin 2014). Lastly, effective outreach will likely require more
communication at the community level, such as through partnerships with local ethnic media and
through work with trusted individuals in the community who can address misperceptions and
misinformation around the ACA.
28
32
RACIAL/ETHNIC DIFFERENCES IN UNINSURANCE RATES UNDER THE ACA
Appendix A. Racial and Ethnic
Classifications
Changes in coverage were examined for six racial/ethnic categories based on the combined responses
to two questions on the ACS. Racial groups were identified using responses to the ACS question, “What
is Person X’s race?” There were 15 response selections, including “some other race” (the complete
question and response choices are provided in this appendix). Responses were then grouped into six
categories, more than one of which could be true for a respondent: White, Black, American Indian or
Alaska Natives, Asian, Pacific Islander, and Other. Latino ethnicity was identified using responses to the
ACS question, “Is Person X of Hispanic, Latino, or Spanish origin?” The racial/ethnic categories used in
this report are as follows:
1.
White, non-Latino, referred to as “white,” includes those who are not Latino and who selected
only “white” as their race.
2.
Latino includes those of Hispanic, Latino, or Spanish origin who are of any race or multiple
races, and not American Indian/Alaska Natives.
3.
Black, non-Latino, referred to as “black,” includes those who are not Latino and who selected
only “black, African Am., or negro” as their race.
4.
Asian/Pacific Islander, non-Latino, referred to as “Asian/Pacific Islander,” includes those who
are not Latino and who selected only Asian or Pacific Islander racial subcategories (Asian
Indian, Japanese, Native Hawaiian, Chinese, Korean, Guamanian or Chamorro, Filipino,
Vietnamese, Samoan, other Asian, or other Pacific Islander).
5.
American Indian/Alaska Natives includes all those who selected American Indian or Alaska
Natives as their race, regardless of ethnicity or additional races identified.
A residual racial/ethnic category includes those who selected “some other race” as their racial
category or selected multiple races and are not Latino or American Indian/Alaska Natives. Because of
the small samples and heterogeneous nature of this group, this category is not analyzed.
33
We then examine three racial/ethnic groups in additional detail. We analyze subgroups by origin for
the Latino and Asian/Pacific Islander groups, since they have a relatively high proportion of foreignborn compared to the three other racial/ethnic groups. We analyze American Indian/Alaska Natives
subgroups by tribe.
APPENDIX A
29
1.
The 11 largest Latino-origin groups (Mexican, Puerto Rican, Salvadoran, Cuban, Dominican,
Guatemalan, Colombian, Honduran, Ecuadorian, Spaniard, and Peruvian) and three other
categories (Other South American, Other Central American, and Other Latino not specified).
Classifications are based on responses given to Question 5 below.
2.
The five largest Asian/Pacific Islander–origin groups (Chinese, Indian, Filipino, Vietnamese, and
Korean) and all other Asian/Pacific Islanders (including those reporting multiple subgroups).
Classifications are based on responses to in Question 6 below, with those selecting multiple
Asian/Pacific Islander subgroups included in the “all other Asian/Pacific Islander” category.
3.
The nine largest identifiable tribes as self-identified in Question 6 below. All other American
Indian/Alaska Natives, including those of mixed race and multiple or unspecified tribes, are
included in the “all other American Indian/Alaska Natives” subcategory.
American Community Survey Questions, 2009.34
5. Is Person 1 of Hispanic, Latino, or Spanish origin?
☐
No, not of Hispanic, Latino, or Spanish origin
☐
Yes, Mexican, Mexican Am., Chicano
☐
Yes, Puerto Rican
☐
Yes, Cuban
☐
Yes, another Hispanic, Latino, or Spanish origin -- Print origin, for example, Argentinean,
Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. _____
6. What is Person 1's race? Mark (X) one or more boxes.
☐ White
☐ Black, African Am., or Negro
☐ American Indian or Alaska Natives -- Print name of enrolled or principal tribe. _____
☐ Asian Indian ☐
Japanese
☐
Native Hawaiian
☐ Chinese
☐
Korean
☐
Guamanian or Chamorro
☐ Filipino
☐
Vietnamese
☐
Samoan
☐ Other
Asian -- Print race, for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on. _____
☐ Other Pacific Islander -- Print race, for example, Fijian, Tongan, and so on. _____
☐ Some other race -- Print race. _____
30
APPENDIX A
Appendix B. Additional Tables
TABLE B.1
Projected Number of Nonelderly Uninsured without ACA, with ACA and Current Medicaid Expansion
Decisions, and with ACA and Full Medicaid Expansion (Nonexpansion States)
Without
ACA
Uninsured
(thousands)
Alabama
681.7
ACA with Current Medicaid Expansion
Decisions
Reduction
in
Uninsured
Decrease
uninsured
(thousands) (thousands)
(%)
489.1
192.6
28.3
ACA with Full Medicaid Expansion
Reduction
in
Uninsured
Decrease
uninsured
(thousands) (thousands)
(%)
264.8
416.9
61.2
Alaska
140.9
73.5
67.4
47.8
50.5
90.4
64.1
Florida
4,153.1
2,592.3
1,560.7
37.6
1,621.3
2,531.7
61.0
Georgia
1,967.8
1,369.3
598.5
30.4
856.4
1,111.4
56.5
Idaho
271.6
174.7
96.9
35.7
103.8
167.8
61.8
Indiana
939.1
614.4
324.6
34.6
344.1
595.0
63.4
Kansas
380.3
258.5
121.8
32.0
160.6
219.7
57.8
Louisiana
820.3
557.5
262.8
32.0
301.1
519.1
63.3
Maine
143.5
81.2
62.3
43.4
52.1
91.4
63.7
Mississippi
531.0
367.3
163.7
30.8
191.9
339.1
63.9
Missouri
815.9
538.8
277.1
34.0
296.0
519.9
63.7
Montana
190.3
110.3
80.1
42.1
61.2
129.2
67.9
Nebraska
222.1
141.0
81.1
36.5
91.0
131.1
59.0
1,612.3
1,007.9
604.4
37.5
623.5
988.8
61.3
Oklahoma
706.6
464.6
242.0
34.3
300.1
406.5
57.5
South Carolina
805.3
543.0
262.3
32.6
327.2
478.2
59.4
South Dakota
107.1
67.1
40.0
37.3
35.5
71.7
66.9
North Carolina
Tennessee
Texas
Utah
Virginia
Wisconsin
a
Wyoming
All
nonexpansion
states
951.2
624.2
327.0
34.4
385.6
565.6
59.5
6,287.8
4,333.9
1,953.9
31.1
2,932.1
3,355.7
53.4
436.4
272.6
163.8
37.5
183.2
253.1
58.0
1,009.3
683.6
325.7
32.3
436.9
572.4
56.7
537.0
221.5
315.5
58.7
199.5
337.6
62.9
88.1
50.9
37.2
42.2
32.5
55.6
63.2
8,161.4
34.3
9,850.9
13,947.8
58.6
23,798.7
15,637.2
Source: HIPSM-ACS 2014. ACA simulated as fully implemented in 2016.
a
Although Wisconsin has not accepted the ACA Medicaid expansion, adults with incomes up to 100 percent of the federal
poverty level are now eligible for Medicaid and can enroll. Before 2014, there was a limited benefits program for low-income
adult nonparents, but enrollment closed.
APPENDIX B
31
TABLE B.2
Projected Number of Nonelderly Uninsured without ACA and with ACA and Current Medicaid
Expansion Decisions, (Expansion States)
Without
ACA
Uninsured
(thousands)
Arizona
ACA with Current Medicaid
Expansion Decisions
Reduction
in
Uninsured
Decrease
uninsured
(thousands) (thousands)
(%)
1,191.5
488.0
703.4
59.0
Arkansas
503.7
194.8
308.9
61.3
California
7,456.5
3,069.6
4,386.9
58.8
Colorado
821.0
382.4
438.6
53.4
Connecticut
330.7
166.0
164.7
49.8
Delaware
89.1
47.9
41.2
46.2
District of Columbia
48.9
23.9
25.0
51.0
Hawaii
104.4
42.4
61.9
59.3
Illinois
1,767.0
749.5
1,017.5
57.6
Iowa
279.3
116.2
163.1
58.4
Kentucky
636.6
232.6
404.0
63.5
Maryland
651.0
331.2
319.8
49.1
Massachusetts
306.7
143.6
163.1
53.2
1,219.2
436.7
782.5
64.2
Minnesota
490.9
242.5
248.4
50.6
Nevada
627.8
304.7
323.1
51.5
Michigan
New Hampshire
New Jersey
New Mexico
New York
North Dakota
Ohio
Oregon
139.8
49.1
90.6
64.8
1,250.6
632.3
618.2
49.4
455.1
207.6
247.6
54.4
2,435.1
1,364.9
1,070.2
43.9
69.4
25.2
44.2
63.7
1,384.2
479.4
904.8
65.4
656.6
281.2
375.3
57.2
Pennsylvania
1,302.3
495.4
806.9
62.0
Rhode Island
127.2
57.8
69.4
54.5
57.0
27.4
29.7
52.0
Washington
997.4
450.3
547.1
54.9
West Virginia
274.1
91.4
182.7
66.6
14,538.8
56.6
Vermont
All expansion states
25,673.0
11,134.2
Source: HIPSM-ACS 2014. ACA simulated as fully implemented in 2016.
32
APPENDIX B
TABLE B.3
Projected Number of Uninsured Whites without ACA, with ACA and Current Medicaid Expansion
Decisions, and with ACA and Full Medicaid Expansion (Nonexpansion States)
Without
ACA
Uninsured
(thousands)
Alabama
ACA with Current Medicaid
Expansion Decisions
Reduction
in
Uninsured
Decrease
uninsured
(thousands) (thousands)
(%)
ACA with Full Medicaid Expansion
Reduction
in
Uninsured
Decrease
uninsured
(thousands) (thousands)
(%)
360.8
244.6
116.3
32.2
123.9
236.9
65.7
Alaska
63.9
31.7
32.2
50.4
22.9
41.0
64.1
Florida
1,632.8
1,016.0
616.8
37.8
579.7
1,053.1
64.5
Georgia
768.0
486.3
281.7
36.7
262.1
505.9
65.9
Idaho
194.5
117.9
76.6
39.4
62.0
132.5
68.1
Indiana
665.8
412.8
253.0
38.0
213.4
452.5
68.0
Kansas
225.1
142.1
83.0
36.9
75.6
149.5
66.4
Louisiana
376.5
239.1
137.4
36.5
131.9
244.6
65.0
Maine
134.4
75.9
58.5
43.5
47.8
86.6
64.5
Mississippi
247.9
159.6
88.3
35.6
86.8
161.1
65.0
Missouri
578.2
367.6
210.6
36.4
194.8
383.4
66.3
Montana
140.8
80.2
60.6
43.0
43.1
97.7
69.4
Nebraska
139.8
81.5
58.3
41.7
45.4
94.4
67.5
North Carolina
762.5
467.9
294.6
38.6
260.0
502.5
65.9
Oklahoma
370.7
233.4
137.3
37.0
138.9
231.8
62.5
South Carolina
401.7
248.5
153.2
38.1
143.3
258.4
64.3
South Dakota
66.0
40.1
25.9
39.2
21.7
44.3
67.1
596.1
361.9
234.2
39.3
206.9
389.2
65.3
Texas
1,578.4
965.2
613.2
38.8
569.7
1,008.7
63.9
Utah
251.1
138.1
113.0
45.0
76.5
174.6
69.5
452.8
282.5
170.3
37.6
153.9
298.9
66.0
356.4
137.8
218.6
61.3
120.4
236.0
66.2
66.1
37.1
28.9
43.8
22.8
43.3
65.5
6,367.9
4,062.4
38.9
3,603.3
6,827.0
65.5
Tennessee
Virginia
Wisconsin
a
Wyoming
All nonexpansion
states
10,430.3
Source: HIPSM-ACS 2014. ACA simulated as fully implemented in 2016.
a
Although Wisconsin has not accepted the ACA Medicaid expansion, adults with incomes up to 100 percent of the federal
poverty level are now eligible for Medicaid and can enroll. Before 2014, there was a limited benefits program for low-income
adult nonparents, but enrollment closed.
APPENDIX B
33
TABLE B.4
Projected Number of Uninsured Whites without ACA and with ACA and Current Medicaid Expansion
Decisions (Expansion States)
Without
ACA
Uninsured
(thousands)
ACA with Current Medicaid
Expansion Decisions
Reduction
in
Uninsured
Decrease
uninsured
(thousands) (thousands)
(%)
Arizona
421.7
139.5
282.3
66.9
Arkansas
325.9
106.1
219.8
67.4
California
1,643.0
577.4
1,065.6
64.9
Colorado
407.6
146.6
261.0
64.0
Connecticut
156.2
62.3
93.9
60.1
Delaware
47.3
21.2
26.1
55.1
District of Columbia
10.3
4.5
5.8
56.3
Hawaii
29.2
9.8
19.4
66.5
Illinois
718.4
267.9
450.5
62.7
Iowa
210.2
75.9
134.2
63.9
Kentucky
507.9
169.3
338.7
66.7
Maryland
219.0
85.0
134.0
61.2
Massachusetts
177.5
69.7
107.7
60.7
Michigan
822.8
276.0
546.7
66.5
Minnesota
322.8
141.5
181.2
56.1
Nevada
229.5
80.6
148.8
64.9
New Hampshire
122.1
40.1
82.0
67.1
New Jersey
416.3
159.8
256.6
61.6
New Mexico
101.6
36.4
65.2
64.2
New York
869.3
426.6
442.7
50.9
48.3
16.8
31.5
65.2
1,013.7
334.0
679.7
67.0
Oregon
428.0
145.8
282.2
65.9
Pennsylvania
874.4
298.7
575.7
65.8
Rhode Island
70.2
22.7
47.4
67.6
Vermont
51.6
24.6
27.1
52.4
Washington
563.3
205.4
357.9
63.5
West Virginia
250.4
81.6
168.9
67.4
4,025.9
7,032.5
63.6
North Dakota
Ohio
All expansion states
11,058.4
Source: HIPSM-ACS 2014. ACA simulated as fully implemented in 2016.
34
APPENDIX B
TABLE B.5
Projected Number of Uninsured Latinos without ACA, with ACA and Current Medicaid Expansion
Decisions, and with ACA and Full Medicaid Expansion (Nonexpansion States)
Without
ACA
Uninsured
(thousands)
Alabama
ACA with Current Medicaid
Expansion Decisions
Reduction
in
Uninsured
Decrease
uninsured
(thousands) (thousands)
(%)
ACA with Full Medicaid Expansion
Reduction
in
Uninsured
Decrease
uninsured
(thousands) (thousands)
(%)
77.9
65.6
12.3
15.8
58.7
19.2
24.6
Alaska
7.5
5.1
2.4
32.2
4.1
3.4
45.4
Florida
1,583.8
977.3
606.4
38.3
692.1
891.7
56.3
435.1
355.5
79.6
18.3
314.2
120.9
27.8
60.5
46.1
14.4
23.7
35.6
24.9
41.1
Indiana
122.5
98.3
24.3
19.8
75.2
47.3
38.6
Kansas
94.6
74.1
20.5
21.7
59.9
34.7
36.7
Louisiana
70.1
54.9
15.2
21.7
46.1
23.9
34.2
2.0
N/A
N/A
N/A
N/A
N/A
N/A
Georgia
Idaho
Maine
Mississippi
32.6
26.5
6.1
18.8
22.8
9.8
30.0
Missouri
64.0
49.1
14.9
23.3
36.9
27.1
42.3
Montana
7.6
5.1
2.5
32.6
4.3
3.3
43.7
Nebraska
51.1
39.8
11.2
22.0
33.0
18.1
35.4
North Carolina
366.4
231.0
135.4
37.0
199.8
166.6
45.5
Oklahoma
123.0
94.5
28.5
23.2
79.5
43.5
35.4
South Carolina
107.0
88.2
18.9
17.6
79.8
27.3
25.5
South Dakota
Tennessee
Texas
Utah
Virginia
Wisconsin
a
Wyoming
All nonexpansion
states
4.3
3.2
1.1
25.9
2.5
1.8
42.0
125.4
104.3
21.1
16.8
94.6
30.8
24.6
3,751.2
2,732.5
1,018.7
27.2
1,994.8
1,756.4
46.8
147.6
109.2
38.4
26.0
92.3
55.3
37.4
209.5
166.2
43.3
20.7
149.1
60.4
28.8
92.7
47.8
44.8
48.4
45.0
47.6
51.4
13.4
7.9
5.5
41.3
6.3
7.1
53.1
7,549.8
5,383.6
2,166.2
28.7
4,128.0
3,421.8
45.3
Source: HIPSM-ACS 2014. ACA simulated as fully implemented in 2016.
Notes: N/A = not applicable. Cells marked “not applicable” had too small of a sample size to provide meaningful data.
a
Although Wisconsin has not accepted the ACA Medicaid expansion, adults with incomes up to 100 percent of the federal
poverty level are now eligible for Medicaid and can enroll. Before 2014, there was a limited benefits program for low-income
adult nonparents, but enrollment was closed.
APPENDIX B
35
TABLE B.6
Projected Number of Uninsured Latinos without ACA and with ACA and Current Medicaid Expansion
Decisions (Expansion States)
Without
ACA
Uninsured
(thousands)
Arizona
ACA with Current Medicaid
Expansion Decisions
Reduction
in
Uninsured
Decrease
uninsured
(thousands) (thousands)
(%)
580.9
281.5
299.4
51.5
Arkansas
68.3
49.9
18.3
26.8
California
4,414.2
1,955.2
2,459.0
55.7
Colorado
320.1
195.5
124.6
38.9
Connecticut
108.3
70.2
38.1
35.2
Delaware
19.2
14.9
4.3
22.4
District of Columbia
10.1
7.2
2.9
28.8
Hawaii
9.6
3.8
5.9
61.0
Illinois
589.9
304.9
285.0
48.3
Iowa
40.2
28.1
12.1
30.1
Kentucky
46.3
33.9
12.4
26.8
Maryland
159.3
124.2
35.1
22.0
65.8
40.5
25.2
38.4
102.0
57.4
44.5
43.7
Massachusetts
Michigan
Minnesota
Nevada
New Hampshire
71.1
53.5
17.6
24.7
288.6
178.8
109.7
38.0
8.2
4.2
4.0
49.0
New Jersey
507.2
320.7
186.5
36.8
New Mexico
248.6
134.3
114.4
46.0
New York
834.8
513.0
321.8
38.5
2.5
N/A
N/A
N/A
90.5
43.4
47.1
52.1
Oregon
151.6
103.3
48.2
31.8
Pennsylvania
159.3
89.0
70.3
44.1
Rhode Island
38.9
25.5
13.4
34.5
1.3
N/A
N/A
N/A
247.3
161.4
85.9
34.7
4.3
1.8
2.6
59.2
9,188.4
4,797.5
4,390.9
47.8
North Dakota
Ohio
Vermont
Washington
West Virginia
All expansion states
Source: HIPSM-ACS 2014. ACA simulated as fully implemented in 2016.
Notes: N/A = not applicable. Cells marked “not applicable” had too small of a sample size to provide meaningful data.
36
APPENDIX B
TABLE B.7
Projected Number of Uninsured Blacks without ACA, with ACA and Current Medicaid Expansion
Decisions, and with ACA and Full Medicaid Expansion (Nonexpansion States)
Without
ACA
Uninsured
(thousands)
Alabama
ACA with Current Medicaid
Expansion Decisions
Reduction
in
Uninsured
Decrease
uninsured
(thousands) (thousands)
(%)
ACA with Full Medicaid Expansion
Reduction
in
Uninsured
Decrease
uninsured
(thousands) (thousands)
(%)
218.9
161.8
57.1
26.1
70.6
148.3
67.8
Alaska
3.5
2.4
1.1
30.8
1.8
1.7
49.3
Florida
731.0
476.5
254.5
34.8
270.8
460.2
63.0
Georgia
635.1
441.9
193.2
30.4
220.9
414.2
65.2
1.9
N/A
N/A
N/A
N/A
N/A
N/A
Indiana
110.9
78.0
32.9
29.6
38.9
72.0
64.9
Kansas
28.9
20.8
8.2
28.2
10.7
18.3
63.2
335.4
236.9
98.5
29.4
105.9
229.5
68.4
1.0
N/A
N/A
N/A
N/A
N/A
N/A
Mississippi
233.0
169.4
63.6
27.3
74.1
158.9
68.2
Missouri
130.8
92.6
38.2
29.2
45.8
85.0
65.0
Montana
1.1
N/A
N/A
N/A
N/A
Idaho
Louisiana
Maine
Nebraska
North Carolina
Oklahoma
South Carolina
South Dakota
N/A
N/A
14.0
8.9
5.2
36.8
5.4
8.6
61.4
377.3
243.8
133.4
35.4
123.9
253.4
67.2
52.7
35.7
17.0
32.3
18.2
34.5
65.5
266.8
187.1
79.7
29.9
90.9
175.9
65.9
2.0
1.0
1.0
49.0
N/A
N/A
N/A
Tennessee
191.1
131.8
59.3
31.0
66.0
125.0
65.4
Texas
616.1
414.6
201.5
32.7
216.9
399.2
64.8
4.9
3.9
1.0
21.1
2.6
2.3
46.6
241.9
164.4
77.6
32.1
83.6
158.3
65.4
48.2
18.9
29.3
60.8
17.4
30.7
63.8
N/A
N/A
N/A
N/A
N/A
N/A
N/A
4,247.1
2,892.8
1,354.3
31.9
1,466.6
2,780.5
65.5
Utah
Virginia
Wisconsin
a
Wyoming
All nonexpansion
states
Source: HIPSM-ACS 2014. ACA simulated as fully implemented in 2016.
Notes: N/A = not applicable. Cells marked “not applicable” had too small of a sample size to provide meaningful data.
a
Although Wisconsin has not accepted the ACA Medicaid expansion, adults with incomes up to 100 percent of the federal
poverty level are now eligible for Medicaid and can enroll. Before 2014, there was a limited benefits program for low-income
adult nonparents, but enrollment was closed.
APPENDIX B
37
TABLE B.8
Projected Number of Uninsured Blacks without ACA and with ACA and Current Medicaid Expansion
Decisions (Expansion States)
Without
ACA
Uninsured
(thousands)
ACA with Current Medicaid
Expansion Decisions
Reduction
in
Uninsured
Decrease
uninsured
(thousands) (thousands)
(%)
Arizona
40.3
14.0
26.3
65.2
Arkansas
84.2
27.1
57.2
67.9
California
336.0
117.7
218.3
65.0
Colorado
34.8
14.6
20.2
58.0
Connecticut
40.6
19.0
21.7
53.3
Delaware
17.0
8.9
8.0
47.2
District of Columbia
25.9
11.0
14.9
57.5
Hawaii
1.0
N/A
N/A
N/A
Illinois
336.8
123.9
212.9
63.2
Iowa
13.6
4.1
9.5
69.8
Kentucky
63.3
21.5
41.8
66.0
Maryland
207.3
88.1
119.2
57.5
Massachusetts
28.6
13.2
15.4
53.9
225.7
75.4
150.4
66.6
Minnesota
41.6
20.7
20.9
50.1
Nevada
43.7
15.1
28.6
65.4
Michigan
New Hampshire
New Jersey
New Mexico
New York
North Dakota
Ohio
Oregon
2.5
1.2
1.3
52.8
171.9
70.4
101.5
59.1
5.1
2.1
3.0
59.6
390.4
224.7
165.6
42.4
1.7
N/A
N/A
N/A
224.5
79.4
145.1
64.6
11.8
3.5
8.3
70.3
Pennsylvania
187.0
69.8
117.2
62.7
Rhode Island
9.2
4.8
4.4
47.4
Vermont
N/A
N/A
N/A
N/A
Washington
39.3
18.1
21.2
53.9
West Virginia
11.7
5.0
6.8
57.8
2,596.4
1,054.9
1,541.5
59.4
All expansion states
Source: HIPSM-ACS 2014. ACA simulated as fully implemented in 2016.
Notes: N/A = not applicable. Cells marked “not applicable” had too small of a sample size to provide meaningful data.
38
APPENDIX B
TABLE B.9
Projected Number of Uninsured Asian/Pacific Islanders without ACA, with ACA and Current
Medicaid Expansion Decisions, and with ACA and Full Medicaid Expansion (Nonexpansion States)
Without
ACA
Uninsured
(thousands)
ACA with Current Medicaid
Expansion Decisions
Reduction
in
Uninsured
Decrease
uninsured
(thousands) (thousands)
(%)
ACA with Full Medicaid Expansion
Reduction
in
Uninsured
Decrease
uninsured
(thousands) (thousands)
(%)
Alabama
10.2
7.2
2.9
28.8
5.5
4.7
45.7
Alaska
11.4
6.5
4.9
42.9
4.8
6.6
57.8
Florida
116.9
69.1
47.7
40.9
45.3
71.6
61.3
Georgia
92.3
61.2
31.1
33.7
43.3
49.0
53.1
3.2
2.1
1.1
33.5
1.3
1.8
57.6
Indiana
19.1
12.6
6.5
34.0
10.0
9.1
47.7
Kansas
12.0
8.3
3.7
30.7
6.2
5.9
48.9
Louisiana
20.5
14.5
6.0
29.1
9.9
10.6
51.8
2.2
N/A
N/A
N/A
1.0
1.2
55.1
Idaho
Maine
Mississippi
8.0
5.3
2.7
33.7
4.2
3.8
47.3
Missouri
15.7
10.6
5.1
32.6
7.9
7.8
49.9
Montana
1.8
N/A
N/A
N/A
N/A
N/A
N/A
Nebraska
5.3
4.1
1.2
23.1
3.2
2.1
39.3
North Carolina
41.7
24.7
17.0
40.7
16.9
24.8
59.5
Oklahoma
14.8
9.6
5.2
35.1
6.8
8.1
54.5
South Carolina
15.0
10.0
5.0
33.6
8.1
6.9
45.8
South Dakota
1.0
N/A
N/A
N/A
N/A
N/A
N/A
18.1
12.4
5.7
31.3
9.3
8.8
48.7
Texas
227.2
146.3
80.9
35.6
100.8
126.5
55.6
Utah
13.1
9.2
3.8
29.5
5.7
7.3
56.3
74.4
50.0
24.4
32.8
36.8
37.6
50.6
17.6
8.1
9.4
53.7
7.8
9.8
55.9
N/A
N/A
N/A
N/A
N/A
N/A
N/A
741.8
475.5
266.2
35.9
336.3
405.5
54.7
Tennessee
Virginia
Wisconsin
a
Wyoming
All nonexpansion
states
Source: HIPSM-ACS 2014. ACA simulated as fully implemented in 2016.
Notes: N/A = not applicable. Cells marked “not applicable” had too small of a sample size to provide meaningful data.
a
Although Wisconsin has not accepted the ACA Medicaid expansion, adults with incomes up to 100 percent of the federal
poverty level are now eligible for Medicaid and can enroll. Before 2014, there was a limited benefits program for low-income
adult nonparents, but enrollment was closed.
APPENDIX B
39
TABLE B.10
Projected Number of Uninsured Asian/Pacific Islanders without ACA and with ACA and Current
Medicaid Expansion Decisions (Expansion States)
Without
ACA
Uninsured
(thousands)
ACA with Current Medicaid
Expansion Decisions
Reduction
in
Uninsured
Decrease
uninsured
(thousands) (thousands)
(%)
Arizona
30.4
15.0
15.4
50.7
Arkansas
11.0
5.0
6.0
54.9
California
833.6
334.8
498.9
59.8
Colorado
26.1
12.1
14.0
53.6
Connecticut
16.2
9.5
6.7
41.4
Delaware
2.5
1.5
1.0
38.6
District of Columbia
1.8
N/A
N/A
N/A
Hawaii
45.5
22.8
22.7
50.0
Illinois
95.7
42.5
53.3
55.6
Iowa
5.8
3.2
2.6
44.6
Kentucky
7.6
3.7
3.9
51.1
Maryland
48.4
25.6
22.7
47.0
Massachusetts
21.9
13.3
8.6
39.2
Michigan
33.6
15.6
18.0
53.5
Minnesota
25.8
13.7
12.1
46.9
Nevada
41.2
20.6
20.6
49.9
New Hampshire
New Jersey
New Mexico
4.0
2.5
1.4
36.2
117.7
59.8
57.9
49.2
5.2
2.7
2.5
47.3
272.8
162.5
110.3
40.4
N/A
N/A
N/A
N/A
Ohio
27.0
12.2
14.7
54.6
Oregon
29.3
14.8
14.5
49.5
Pennsylvania
55.1
27.1
28.0
50.8
Rhode Island
4.8
3.0
1.9
38.5
Vermont
1.8
N/A
N/A
N/A
85.6
41.2
44.4
51.9
1.8
N/A
N/A
N/A
1,852.9
868.5
984.4
53.1
New York
North Dakota
Washington
West Virginia
All expansion states
Source: HIPSM-ACS 2014. ACA simulated as fully implemented in 2016.
Notes: N/A = not applicable. Cells marked “not applicable” had too small of a sample size to provide meaningful data.
40
APPENDIX B
TABLE B.11
Projected Number of Uninsured American Indian/Alaska Natives without ACA, with ACA and
Current Medicaid Expansion Decisions, and with ACA and Full Medicaid Expansion (Nonexpansion
States)
Without
ACA
Uninsured
(thousands)
ACA with Current Medicaid
Expansion Decisions
Reduction
in
Uninsured
Decrease
uninsured
(thousands) (thousands)
(%)
ACA with Full Medicaid Expansion
Reduction
in
Uninsured
Decrease
uninsured
(thousands) (thousands)
(%)
Alabama
10.1
7.1
3.0
30.1
4.7
5.4
53.8
Alaska
53.3
27.3
26.0
48.8
16.6
36.7
68.9
Florida
42.9
26.5
16.4
38.2
15.7
27.2
63.4
Georgia
19.0
12.4
6.6
34.7
8.4
10.6
55.8
Idaho
10.5
7.1
3.4
32.7
4.1
6.5
61.4
Indiana
11.2
6.8
4.4
39.2
3.7
7.5
67.2
Kansas
15.8
10.5
5.2
33.1
6.7
9.1
57.8
Louisiana
13.2
9.1
4.1
31.3
5.8
7.5
56.5
3.7
1.6
2.1
57.3
1.4
2.3
62.4
Maine
Mississippi
7.5
5.2
2.3
30.7
3.1
4.5
59.4
Missouri
19.1
13.1
6.0
31.3
7.7
11.5
60.0
Montana
37.8
22.5
15.3
40.6
12.1
25.7
67.9
Nebraska
North Carolina
Oklahoma
9.2
5.8
3.5
37.6
3.2
6.0
64.8
50.6
32.2
18.3
36.3
18.1
32.5
64.2
139.7
87.4
52.3
37.4
54.1
85.7
61.3
South Carolina
7.0
5.2
1.8
25.9
2.6
4.4
62.7
South Dakota
33.8
22.3
11.4
33.8
10.1
23.6
70.0
Tennessee
12.9
9.1
3.8
29.6
5.8
7.1
54.7
Texas
77.7
52.0
25.8
33.1
35.2
42.5
54.7
Utah
15.9
9.5
6.4
40.2
4.5
11.4
71.7
14.9
9.8
5.1
34.0
6.8
8.1
54.5
16.6
7.0
9.6
57.8
6.7
9.9
59.6
7.1
4.6
2.5
35.4
2.9
4.2
59.0
629.5
394.1
235.5
37.4
239.8
389.7
61.9
Virginia
Wisconsin
a
Wyoming
All nonexpansion
states
Source: HIPSM-ACS 2014. ACA simulated as fully implemented in 2016.
a
Although Wisconsin has not accepted the ACA Medicaid expansion, adults with incomes up to 100 percent of the federal
poverty level are now eligible for Medicaid and can enroll. Before 2014, there was a limited benefits program for low-income
adult nonparents, but enrollment was closed.
APPENDIX B
41
TABLE B.12
Projected Number of Uninsured American Indian/Alaska Natives without ACA and with ACA and
Current Medicaid Expansion Decisions (Expansion States)
Without
ACA
Uninsured
(thousands)
Arizona
ACA with Current Medicaid
Expansion Decisions
Reduction
in
Uninsured
Decrease
uninsured
(thousands) (thousands)
(%)
107.8
34.3
73.5
68.2
Arkansas
11.1
5.2
6.0
53.7
California
144.5
54.1
90.4
62.5
Colorado
24.6
10.5
14.1
57.4
3.5
1.5
1.9
56.4
Connecticut
Delaware
2.0
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Hawaii
2.4
N/A
N/A
N/A
Illinois
13.0
5.1
7.9
60.8
Iowa
7.0
3.9
3.1
44.5
Kentucky
6.7
2.7
4.0
59.8
Maryland
8.0
4.2
3.8
47.2
District of Columbia
Massachusetts
3.5
1.6
1.9
53.8
Michigan
21.1
7.7
13.4
63.5
Minnesota
21.5
9.8
11.7
54.4
Nevada
15.5
5.5
10.0
64.7
New Hampshire
1.6
N/A
N/A
N/A
New Jersey
17.4
11.9
5.5
31.8
New Mexico
93.0
31.3
61.7
66.3
New York
29.9
15.7
14.2
47.4
North Dakota
15.8
6.3
9.5
59.9
Ohio
12.9
4.4
8.5
66.0
Oregon
27.3
10.9
16.4
59.9
Pennsylvania
9.6
3.1
6.5
67.6
Rhode Island
1.6
N/A
N/A
N/A
Vermont
1.0
N/A
N/A
N/A
41.9
16.3
25.6
61.1
4.0
1.5
2.6
63.6
648.5
250.8
397.7
61.3
Washington
West Virginia
All expansion states
Source: HIPSM-ACS 2014. ACA simulated as fully implemented in 2016.
Notes: N/A = not applicable. Cells marked “not applicable” had too small of a sample size to provide meaningful data.
42
APPENDIX B
TABLE B.13
Projected Statistic (Effect Size) to Assess Whether Coverage Rates for Racial/Ethnic Minority Groups
Narrow Compared with White Coverage Rates under the ACA
Black
Latino
Asian/Pacific
Islander
American
Indian/
Alaska
Native
All states
Without ACA (A)
0.071
0.205
0.034
0.063
ACA with current Medicaid decisions (B)
0.073
0.187
0.029
0.045
ACA with full Medicaid expansion (C)
0.044
0.195
0.043
0.041
0.002
-0.019
-0.005
-0.017
-0.026
-0.010
0.009
-0.021
Without ACA (A)
0.051
0.193
0.041
0.060
ACA with current Medicaid decisions (B)
0.041
0.177
0.048
0.039
-0.010
-0.016
0.007
-0.021
Without ACA (A)
0.079
0.230
0.039
0.065
ACA with current Medicaid decisions (B)
0.080
0.213
0.034
0.051
ACA with full Medicaid expansion (C)
0.044
0.224
0.043
0.044
0.001
-0.016
-0.005
-0.013
-0.035
-0.005
0.004
-0.021
Difference (narrowing coverage differential
with white is negative; widening is positive)
Without ACA vs. ACA with current
Medicaid decisions (B minus A)
Without ACA vs. ACA with full
Medicaid decisions (C minus A)
Medicaid expansion states
Relative differences (narrowing is negative;
widening is positive)
Without ACA vs ACA with current
Medicaid decisions (B minus A)
Nonexpansion states
Relative differences (narrowing is negative;
widening is positive)
Without ACA vs. ACA with current
Medicaid decisions (B minus A)
Without ACA vs. ACA with full
Medicaid decisions (C minus A)
Source: HIPSM-ACS 2014. ACA simulated as fully implemented in 2016.
Note: The statistic presented is an “effect size” as described in the methods section.
APPENDIX B
43
Notes
1.
Robin A. Cohen and Michael E. Martinez, “Health Insurance Coverage: Early Release of Quarterly Estimates
from the National Health Interview Survey, January 2010–March 2014,” National Center for Health Statistics,
accessed November 21, 2014,
http://www.cdc.gov/nchs/data/nhis/earlyrelease/quarterly_estimates_2010_2014Q11.pdf.
2.
“State Medicaid and CHIP Income Eligibility Standards,” Centers for Medicare and Medicaid Services, accessed
November 21, 2014. In addition, Pennsylvania is slated to expand Medicaid eligibility in January 2015. See
Marilyn Tavenner, letter to Secretary Mackereth, August 28, 2014, http://www.medicaid.gov/Medicaid-CHIPProgram-Information/By-Topics/Waivers/1115/downloads/pa/pa-healthy-ca.pdf.
3.
Those whose incomes are between 100 and 400 percent of FPL, who are not eligible for any public coverage
program such as Medicaid, who are legally present in the United States, and who do not have an affordable
offer of coverage from an employer are eligible for subsidized private coverage in the health insurance
Marketplaces. This means that in a state that has expanded Medicaid eligibility, subsidy eligibility ends at 138
percent of FPL. Legally present immigrants who do not qualify for Medicaid because they have not been
residing in the United States for five years are also eligible for subsidized coverage, even if their incomes are
below 100 percent of FPL.
4.
Also, many adults with family income between 100 and 138 percent of FPL who live in expansion states and
would have been eligible for Medicaid are barred from subsidized Marketplace coverage because of an offer of
employer-sponsored insurance coverage to a family member. If any family member is offered single coverage
for which his or her share of the premium is less than 9.5 percent of family income, then the entire family is
ineligible for subsidized coverage.
5.
Authors’ tabulations using HIPSM-ACS, 2014.
6.
“State Medicaid and CHIP Income Eligibility Standards,” Centers for Medicare and Medicaid Services. In
addition, Pennsylvania is slated to expand Medicaid eligibility in January 2015. See Marilyn Tavenner, letter to
Secretary Mackereth, August 28, 2014, http://www.medicaid.gov/Medicaid-CHIP-Program-Information/ByTopics/Waivers/1115/downloads/pa/pa-healthy-ca.pdf.
7.
For an overview of HIPSM, see Urban Institute (2010). For more information about methodology, see “Further
Methodological Information for ‘Tax Preparers Could Help Most Uninsured Get Covered,’” Urban Institute,
accessed November 11, 2014,
http://www.urban.org/health_policy/health_care_reform/taxfilingmethodology.cfm.
8.
Previous estimates based on HIPSM (e.g., Holahan et al. 2012) differ slightly, particularly in the estimate of
potential new Medicaid eligibles. Our current estimates take into account final HHS and Treasury regulations
on how Medicaid eligibility should be computed under the ACA. In addition, previous estimates were based on
the 2010 ACS, while the current estimates are based on three years of the ACS aged to 2016. Further, the
number of uninsured has declined since 2010, disproportionately reducing the number of very low income
uninsured, and economic conditions and thus the underlying income distribution have also changed since
2010.
9.
The approach allows new coverage options to be assessed without simply extrapolating from historical data. It
considers such factors as affordability (premiums and out-of-pocket health care costs for available insurance
products), health care risk, whether the individual mandate would apply, and family disposable income.
10. For example, if someone is currently eligible for Medicaid but not enrolled, he or she (or his or her parents)
have shown a preference against Medicaid. He or she will be less likely to enroll in Medicaid under the ACA
than a similar person who becomes newly eligible for Medicaid and thus has not had a chance to express a
preference. We use such preferences to customize individual utility functions so that people’s current choices
score the highest among their current coverage choices, and these preferences affect their behavior under the
ACA.
11. See appendix A for classification details. The 4.1 million nonelderly adults in the “other non-Latino”
racial/ethnic category are not discussed in this paper because that category combines heterogeneous groups.
Overall, findings for the “other non-Latino” group largely mirror findings for whites.
44
NOTES
12. “Summary of Immigrant Eligibility Restrictions under Current Law,” Assistant Secretary for Planning and
Evaluation, last modified April 28, 2011, accessed November 24, 2014,
http://aspe.hhs.gov/hsp/immigration/restrictions-sum.shtml.
13. For comparison, the second-largest concentration of undocumented individuals is among Asians and Pacific
Islanders. Fully 14.4 percent of the undocumented are estimated to be Asians and Pacific Islanders.
Undocumented individuals are estimated to make up 12.1 percent of Asians and Pacific Islanders.
14. Percentage-point differences are not shown in the tables; computations are based on projections in the tables.
15. James P. Scanlan, “How Measures Are Affected by the Prevalence of an Outcome,” letter in response to
Clemans-Cope et al. (2012),
http://content.healthaffairs.org/content/31/5/920.full/reply#healthaff_el_476249.
16. When two groups differ in their uninsurance rate, if the overall uninsurance rate (i.e., the rate of uninsurance
across both groups) decreases without any change in the underlying difference between the groups, then (1)
the relative difference in uninsurance rates between the groups tends to be greater, and (2) the relative
difference in rates of having health coverage tends to be smaller.
17. If the relative changes in both the uninsured and insured rates are consistent—either larger or smaller for one
group compared to another group—we can conclude that the difference in health coverage between the two
groups has narrowed (or widened).If the relative changes in the uninsured and insured rates are not in the
same direction, however, we cannot draw conclusions about relative differences in uninsurance rates between
groups without additional information. In all cases presented here, the relative changes in the uninsured and
insured rates were not consistent, suggesting that computation of a measure such as “effect size” was
necessary.
18. For general information on the measure computed here, effect size, see Harper and Lynch (2005). Also see
Scanlan (2013).
19. The Public Use Microdata Areas are the smallest statistically representative geographic area on the ACS.
20. Lisa Clemans-Cope, Hannah Recht, and Anna Spencer, “Racial/Ethnic Differences in Uninsurance Rates under
the ACA: Where You Live Matters,” MetroTrends (blog), December 16, 2014,
http://blog.metrotrends.org/2014/12/racialethnic-differences-uninsurance-rates-aca-live-matters.
21. Calculations based on table 1.
22. Estimates include calculations based on table 1.
23. Calculations based on table 1.
24. Calculations based on table 1.
25. Calculations based on table 1.
26. Although we define high-impact states as those that together account for half the projected coverage gains
under the ACA with full Medicaid expansion, the actual proportions are slightly over 50 percent because of the
need to include whole states. High-impact states make up 50.6 percent (black) to 54.0 percent (Latino) of
coverage gains by race.
27. Calculations based on table 9.
28. The share of American Indian/Alaska Natives in the “All other Asian/Pacific Islander” category is low for
several states. In four states, the share of American Indian/Alaska Natives in the “All other Asian/Pacific
Islander” category is less than half (19 percent in New Mexico, 21 percent in South Dakota, 36 percent in
North Dakota, and 46 percent in Arizona). In another five states, the share in the “All other Asian/Pacific
Islander” category is less than the national average (52 percent in North Carolina, 53 percent in Utah, 54
percent in Minnesota, 56 percent in Alaska, and 59 percent in Mississippi). See appendix A for details on race
and tribe classification.
29. For example, California recently turned down an offer from the California Endowment of $6 million toward the
renewal process for those newly enrolled in Medi-Cal, a decision that has led to some criticism, given the
backlog of Medi-Cal applicants. See Anna Gorman, “Advocates Say California Is Rejecting ‘Free Money’ to
Renew Poor People’s Insurance,” Kaiser Health News, July 4, 2014,
NOTES
45
http://capsules.kaiserhealthnews.org/index.php/2014/07/advocates-say-california-is-rejecting-free-moneyto-renew-poor-peoples-insurance/
30. Consumer Reports, “Having trouble proving your identity to HealthCare.gov?” December 18, 2013,
http://www.consumerreports.org/cro/news/2013/12/how-to-prove-your-identity-on-healthcaregov/index.htm.
31. See also Sonya Schwartz, “We Can Fix This, People! More than Half of Uninsured Parents Are Latino,”
CHIRblog, September 12, 2014, http://chirblog.org/we-can-fix-this-people-more-than-half-of-uninsuredparents-are-hispanic; and “Improving the Road to ACA Coverage: Lessons Learned on Outreach, Education,
and Enrollment for Asian American, Native Hawaiian, and Pacific Islander Communities,” Asian & Pacific
Islander American Health Forum, September 2014, accessed November 24, 2014,
http://www.apiahf.org/resources/resources-database/improving-road-aca-coverage-lessons-learnedoutreach-education-and-enro.
32. “Improving the Road to ACA Coverage,” September 2014.
33. This group of 4.1 million nonelderly who selected neither American Indian/Alaska Native as a race nor Latino
as an ethnicity is made up of 3.6 million who selected multiple races and 566,000 nonelderly respondents who
selected only “other race.”
34. “Questions on the Form and Why We Ask,” US Census Bureau, accessed November 24, 2014,
http://www.census.gov/acs/www/about_the_survey/questions_and_why_we_ask/.
46
NOTES
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REFERENCES
47
About the Authors
Lisa Clemans-Cope is a senior research associate in the Health Policy Center at the
Urban Institute. Her areas of expertise include health insurance reform legislation and
regulation, Medicaid and the Children’s Health Insurance Program (CHIP), dual health
spending, access to and use of health care, private insurance, eligibles health-related
survey data, and Medicaid claims data. Her current work includes quantitative and
qualitative analyses of federal and state implementation of the Affordable Care Act,
and an evaluation of children’s access to and use of health services in CHIP. ClemansCope has a BA in economics from Princeton University and a PhD in health economics
from the Johns Hopkins Bloomberg School of Public Health.
Matthew Buettgens is a senior research analyst in the Health Policy Center at the
Urban Institute, where he is the mathematician leading the development of Urban’s
Health Insurance Policy Simulation Model (HIPSM). The model is currently being used
to provide technical assistance for health reform implementation in Massachusetts,
Missouri, New York, Virginia, and Washington as well as to the federal government. His
recent work includes a number of research papers analyzing various aspects of national
health insurance reform, both nationally and state-by-state. Research topics have
included the costs and coverage implications of Medicaid expansion for both federal
and state governments; small firm self-insurance under the Affordable Care Act and its
effect on the fully insured market; state-by-state analysis of changes in health
insurance coverage and the remaining uninsured; the effect of reform on employers;
the affordability of coverage under health insurance exchanges; and the implications of
age rating for the affordability of coverage. Buettgens was previously a major
developer of the Health Insurance Reform Simulation Model—the predecessor to
HIPSM—used in the design of the 2006 Roadmap to Universal Health Insurance
Coverage in Massachusetts.
Hannah Recht is a research assistant in the Health Policy Center at the Urban Institute,
where she works with the Health Insurance Policy Simulation Model to predict and
analyze the effects of the Affordable Care Act. Her recent work has included providing
technical assistance for New York State, state-level analysis of the current uninsured,
an examination of children in complex coverage situations, and the implications of
48
ABOUT THE AUTHORS
Medicaid expansion. Recht received her BA in mathematics and statistics from the
University of Rochester.
ABOUT THE AUTHORS
49
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Washington, DC 20037
www.urban.org